Hi..

You can use star excursion balance test (SEBT) for pre and post data comparisons typically to check whether your stabilization procedure has improved Balance of a person..

It is a reliable and valid tool..

This sounds great. Let me look it up. Thank you.

What aspects of chronic ankle instability are you examining?  If you are looking for patient based outcomes, there are multiple instruments that have been validated to CAI related impairments and some have been endorsed by the International Ankle Consortium (see link). 

However, it should be noted that the questionnaires used within the fields of athletic training/physical therapy are different from those typically reported within the orthopedic literature.  It may be best to capture patient perspectives from both areas.

There are also a number of clinical based tests.  The SEBT is certainly a good measure of dynamic balance.  The Time in Balance test and the foot lift test are also excellent choices for balance related outcome measures.  The weight bearing lunge test has been established as a good measure of dorsiflexion range of motion and is easy to implement.  There are also numerous research based (i.e. instrumented outcomes) that could be used depending on what your primary question is.

http://www.ncbi.nlm.nih.gov/pubmed/23902805

Great. Thank you. My patient population is mostly veterans in 30-50's. No exactly athletic. Which clinical test do you guys think would be the best (and safest) for non-anthletic population?

What is the outcome(s) that you are focusing on improving through either surgical or conservative interventions?  That will help narrow down the choices of clinical outcome measures.

Improvement in stability is the primary thing I want to evaluate

Postural stability or joint stability?  If joint stability is the primary outcome, range of motion (especially in the frontal plane) and laxity tests are the most common clinical outcomes that I have seen both in the literature and practice.  I have arthrometry reported but that gets away from the clinical tests that you mentioned.  You could look at stiffness of the joint but I am not sure if there is a gold standard in how to assess that from a clinical perspective.  The below link may be a starting point.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3295205/

Thank you. I was wanting to evaluate joint stability initially but after reading more literature (including your group's), I'm finding postural stability is clinically important as well. I'm finding however that ROM and laxity tests are very operator dependent. Thanks for your input. I will read up on more stuff. Today, I saw 4 patients with chronic ankle instability and tested on a force plate. All the patient had significantly more excursion on the affected ankle than his/her contralateral unaffected ankle.

If you want to make your clinical results comparable to others, I would suggest three easy-to-use tools:

• AOFAS hindfoot scale: the most commonly used clinical score for ankle problems;
• VAS: pain is one of the two most important aspects for patients. (There is also a more complex version of a VAS-system, measuring pain in different situations. However I suggest to use a simple VAS for max pain in any situation.);
• Ankle Activity Score: a good tool to monitor changes in activity, which is the other of the two most important patient-related aspects. For this see also the link below. Important to notice, that you must record activity levels at least three different times: before injury, before surgery and at follow-up. (Of course you can record follow-up data as often you want.) The main point in changes of activity-level is how patients recover to pre-injury-levels at follow-up, and how impaired they were through the injury. Thus activity-level on its own is not informative, however its changes say a lot!  

I would not bother to use any measurements simply to quantify the pure mechanical stability of the ankles. When doing surgery alone as intervention, the changes of functional stability will be a result of a better mechanical stability!

Article Development of a New Activity Score for the Evaluation of An...

Nice article. Thanks.

It depends what you want to quantify.  Instability is a symptom - "my ankle gives way".  Laxity is the physical sign of abnormally increased joint mobility for that particular person - eg talar tilt, anterior draw test.  It is important to make the distinction, because some patients have both - and may be a surgical candidate for a lateral ligament reconstruction.  Others may have instability without laxity, where the cause is usually intra-articular pathology (synovial impingement, loose body etc).  And some have laxity without instability - these are "normal" hypermobile individuals with intact proprioception.

So if you want to measure instability, use a foot and ankle PROM such as MOXFQ (not AOFAS as this has been officially withdrawn owing to poor performance) plus a clinical test of dynamic balance (SEBT is mentioned above, although I have no particular experience with this).

If you want to measure laxity, inversion stress X rays to measure difference in talar tilt between left and right sides and between pre- and post-op would be the closest you can get to a 'gold standard'.  However, there is no cut-off that defines abnormal laxity (some authors say 10 degrees, but in my view that is too arbitrary as individuals vary!).  Documenting differences between left and right, and between pre- and post-op would be far more important for your research.

Stephen, thanks. great info. I think I will measure both functional/mechanical components for both ankles so I cover everything. Do you have any experience with Telos device?

Hi Naohiro,

For functional ankle instability (better to say percieved ankle instability) you can use Cumberland Ankle Instability Tool (CAIT)

For mechanical ankle instability "I think" the best device is an ankle arthrometer.

I have previously used an ankle arthrometer developed by Blue Bay Research, Inc., Milton, FL. One of the attached publications (ALRI-CadaverStudy) describes a customized version that was developed to quantify transverse plane rotation, which appears to be the most important component of ankle instability. 

If you plan to use a survey responses for quantification of ankle function, I recommend that you use the Foot and Ankle Ability Measure (FAAM):

Martin RL, Irrgang JJ, Burdett RG, Conti SF, Van Swearingen JM. Evidence of validity for the Foot and Ankle Ability Measure (FAAM). Foot & Ankle International. 2005 Nov 1;26(11):968-83.

I had a patient with  pes cavus feet and he was elderly and very active as far as hiking all over the word he had instability of his right ankle and wore and ankle brace for years

I examined him and his crural muscle powers  was 5/5 bl

I ordered an MRI on his right ankle expecting that at least atf ligament was torn but the Mri stated that all of his lateral ankle ligament s were intact but his P. brevis and Longus were torn degenerated.

I could not clinically  difurentiate muscle power of the lateral crurals right from left

all of his lateral ligaments were intact

this patient had a peroneal allograft  and has been well

Steven Levitz dpm

Hiro,

I have used the Telos device from Austin Medical. The SE 2000 new model TELOS allows for stress exams of the Ankle (Anterior Drawer/Lateral, Talar Tilt/AP, Syndesmosis Joint and Subtalar Joint).  We have one at JPS if you would like to use it in your evaluations.

Hi Naohiro,

I believe it is important to include measures that document changes in laxity or instability.  The aforementioned arthrometer from Blue Bay is a good example.  Have a look at some of the published applications at their site (below) to help you decide on the approach you'll take.

http://bluebayres.com/ankle-arthrometer-bibliography/